Laserfiche WebLink
'f <br /> jAPPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1.601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 1 (7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE ►�7 !� �� <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Ljobddress ;fItCity Lot Size/Acreager's Nam Address / �'W 1� Phoneactor Address License No.-`s~ Phone <br /> OF WELL/PUMP; NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service We11 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL 0TH PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS N SPECIFiCAT10NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> fl Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications <br /> F] Public Ia Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I lrrigation prox:.Depth l I Eastern Surface Seal Installed by rj <br /> Repair Work Done ype of Pump H.P. State Work Done <br /> Well Destru ❑ Well Diameter Sealing Material & Depth. <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1 I DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS [ l Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation 'Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California:"Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." <br /> The applic t must call for all r e clions plete drawing on reverse side. <br /> �y C; <br /> Signed ✓ Title: ._..... - Date:75 1,l. ---�2 <br /> DEPARTMENT USEONLY <br /> Application Accepted by Date v ` `-' Area <br /> Pit or Grout Inspection by Date Final Inspection by 1 U Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Gan Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> • EH 13.24 IREV. w 51 <br />